Thrombolysis with Tenecteplase for Acute Ischemic Stroke in Patients taking Direct Oral Anticoagulants

Prior treatment

• Contraindication to intravenous thrombolysis, except DOAC therapy
• Concomitant therapy with antithrombotic medications, except DOACs
• Any anticipated surgical intervention within 12 hours

Other illness

• Significant pre-stroke disability (mRS > 3)

Other

• Reversal or planned reversal of anticoagulation with idarucizumab or andexanet alfa
• Anticipated stenting of cervical or intracranial artery within 12 hours
• Anticipated coronary angioplasty within 12 hours

• Age ≥ 18 years
• Clinical diagnosis of acute stroke with disabling deficit
• National Institutes of Health Stroke Scale (NIHSS) score at least 2
• Recent intake (within 48 hours prior to enrolment) of a direct oral anticoagulant (apixaban, rivaroxaban, edoxaban, or dabigatran)
• No evidence of any intracranial haemorrhage on cerebral imaging (CT or MRI) performed after stroke onset and no earlier than 60 minutes before enrolment
• Stroke symptoms not known to have been present for > 6 h
• For patients not known to have been awake and without acute stroke symptoms within 4.5 hours prior to enrolment, additional imaging criteria must be satisfied: a) If stroke symptoms are known to have been present for > 4.5 h (late time window): core/penumbra mismatch on MR or CT perfusion imaging; b) If stroke symptoms are not known to have been present for > 4.5 h (unknown time window): core/penumbra mismatch on MR or CT perfusion imaging; or DWI/FLAIR mismatch on MR imaging.